Lab Report
Lab Report
Source Object: Lab Report
The Lab Report source object is a fundamental component of healthcare data systems, providing a comprehensive record of laboratory test results. It plays a critical role in capturing, storing, and presenting lab results for patient care and documentation.
Overview
Lab Reports are essential documents that contain detailed information about the results of laboratory tests conducted on a patient. These reports are used by healthcare providers to monitor a patient's health, diagnose medical conditions, and make informed treatment decisions.
Usage
The Lab Report source object serves the following key purposes:
- Test Results: It contains detailed information about the results of various laboratory tests. This includes data about the test name, code, units of measurement, value, and reference ranges.
- Patient Information: The report is associated with a specific patient, and it includes patient identification details such as name and date of birth.
- Physician Information: It includes the name of the physician or healthcare provider who ordered the tests and the date on which the tests were ordered.
- Practice Information: Information about the healthcare practice where the tests were conducted is recorded. This may include the practice name and location.
- Report Metadata: The Lab Report object contains metadata, such as the report's creation date, reported date, and any custom titles associated with the report.
- Test Grids: The report may contain multiple test grids, each representing a group of related tests. Each grid provides detailed results for the tests it contains, including information on abnormal flags, reference ranges, and test categories.
By using the Lab Report source object, healthcare providers can access a structured and comprehensive record of a patient's laboratory test results. This information is vital for making accurate diagnoses, determining treatment plans, and monitoring a patient's overall health. Additionally, it provides a standardized way to store and retrieve test results, contributing to improved patient care and better-informed healthcare decisions.
Mapping Table
| Data Field | Source Field Data Type | Resource Mapping Context | Source Data Field Cardinality | Source Data Field Description | Example Value | Source Data Field Validation Rule | Mapped FHIR Resource | Mapped FHIR Data Field | Augmented Mapping | Associated Coding System | Associated FHIR Data Field Extension | Mapped FHIR Data Field Type |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| chart_date | DateTime | Top Level | 0..1 | - | 2020-06-05T23:00:29Z | - | DiagnosticReport | extension[*].valueString | - | NA | chart_date | string |
| created_date | DateTime | Top Level | 0..1 | - | 2020-06-05T23:03:43Z | - | DiagnosticReport | extension[*].valueString | - | NA | created_date | string |
| custom_title | String | Top Level | 0..1 | - | null | - | DiagnosticReport | code.text | - | NA | - | string |
| deleted_date | DateTime | Top Level | 0..1 | - | null | - | DiagnosticReport | extension[*].valueString | - | NA | deleted_date | string |
| document_date | DateTime | Top Level | 0..1 | - | 2020-11-05T21:05:00Z | - | DiagnosticReport | extension[*].valueString | - | NA | document-date | string |
| files | TBD | Top Level | 0..* | - | - | - | DiagnosticReport | presentedForm[1].data | - | NA | - | TBD |
| id | Long | Top Level | 1..1 | read-only | 140768147734599 | - | DiagnosticReport | id | - | NA | - | TBD |
| images | TBD | Top Level | 0..* | - | - | - | DiagnosticReport | media[*].comment | - | NA | - | TBD |
| patient | Integer | Top Level | 1..1 | required | 140767518130177 | - | DiagnosticReport | subject.reference | - | NA | - | TBD |
| physician | Integer | Top Level | 1..1 | - | 140750846885890 | - | DiagnosticReport | extension[*].valueInteger | - | NA | physician | integer |
| practice | Integer | Top Level | 1..1 | - | 140750842363908 | - | DiagnosticReport | extension[*].valueInteger | - | NA | practice | integer |
| report_type | ValueSet | Top Level | 1..1 | required | Lab | - | DiagnosticReport | category.text | - | NA | report_type | string |
| reported_date | DateTime | Top Level | 1..1 | required | 2020-11-05T22:17:34Z | - | DiagnosticReport | issued | - | NA | - | TBD |
| requisition_number | String | Top Level | 0..1 | required | 555 | - | DiagnosticReport | basedOn.reference | - | NA | - | TBD |
| signed_by | Integer | Top Level | 0..1 | - | null | - | DiagnosticReport | extension[*].valueString | - | NA | signed-by | string |
| signed_date | DateTime | Top Level | 0..1 | - | null | - | DiagnosticReport | extension[*].valueString | - | NA | signed_date | string |
| tags | TBD | Top Level | 0..* | - | - | - | DiagnosticReport | contained[].extension[].valueString | - | NA | tags | string |
| vendor | Integer | Top Level | 0..1 | - | 1407508423639 | - | DiagnosticReport | performer[1].reference | - | NA | - | TBD |
| grids.results | Object | Contained | 0..* | - | - | - | Observation | - | - | NA | - | TBD |
| grids.results.abnormal_flag | ValueSet | Contained | 0..1 | - | - | Below low normal, Above high normal, Below lower panic limits, Above upper panic limits, Below absolute low-off instrument scale, Above absolute high-off instrument scale, Normal (applies to non-numeric results), Abnormal (applies to non-numeric results), Very abnormal (applies to non-numeric units, analogous to panic limits for numeric units), Positive result, Negative result, Intermediate result, Significant change up, Significant change down, Better-use when direction not relevant, Worse-use when direction not relevant, Susceptible. Indicates for microbiology susceptibilities only., Resistant. Indicates for microbiology susceptibilities only., Intermediate. Indicates for microbiology susceptibilities only., Moderately susceptible. Indicates for microbiology susceptibilities only., Very susceptible. Indicates for microbiology susceptibilities only., Critical, Abnormal, Beta-lactamase Pos (B-lactamase antibiotic resistant)., Not Applicable, Very High, Negative | Observation | contained[].contained[].extension[*].valueString | - | NA | abnormal-flag | string |
| grids.results.is_abnormal | Boolean | Contained | 0..1 | required | FALSE | true, false | Observation | contained[].contained[].extension[*].valueBoolean | - | NA | is-abnormal | boolean |
| grids.results.note | String | Contained | 0..1 | - | - | - | Observation | contained[].contained[].note.text | - | NA | - | markdown |
| grids.results.reference_max | String | Contained | 0..1 | required | 8.3 | - | Observation | contained[].contained[].referenceRange.high.value | - | NA | reference-max | TBD |
| grids.results.reference_min | String | Contained | 0..1 | required | 6.1 | - | Observation | contained[].contained[].referenceRange.low.value | - | NA | - | TBD |
| grids.results.status | ValueSet | Contained | 0..1 | - | FINAL | CORRECTED, DELETED, FINAL, PENDING, PRELIMINARY, RESULTS ENTERED -- NOT VERIFIED, PARTIAL, RESULTS STATUS CHANGE TO FINAL. RESULTS DID NOT CHANGE ( DONT TRANSMIT TEST)., RESULT CANCELED DUE TO NON-PERFORMANCE, ERROR, AMENDED | Observation | contained[].contained[].status | - | NA | - | TBD |
| grids.results.test | Object | Contained | 0..1 | - | - | - | Observation | - | - | NA | - | TBD |
| grids.results.test_category | Object | Contained | 0..1 | - | - | - | Observation | - | - | NA | - | TBD |
| grids.results.test_category.description | String | Contained | 0..1 | cannot be none or null | COMP. METABOLIC PANEL | - | Observation | contained[].contained[].category.extension[*].valueString | - | NA | test-category-description | string |
| grids.results.test_category.value | String | Contained | 0..1 | - | 1245 | - | Observation | contained[].contained[].category.extension[*].valueString | - | NA | test-category-value | string |
| grids.results.test.code | String | Contained | 0..1 | - | 10510 | - | Observation | contained[].contained[].code.coding[*].code | - | NA | - | TBD |
| grids.results.test.loinc | String | Contained | 0..1 | cannot be none or null | 13980-8 | - | Observation | contained[].contained[].code.extension[*].valueString | - | LOINC | lonic | string |
| grids.results.test.name | String | Contained | 0..1 | - | Protein-Total | - | Observation | contained[].contained[].code.coding[*].display | - | NA | - | TBD |
| grids.results.text | String | Contained | 0..1 | - | - | - | Observation | contained[].contained[].extension[*].valueString | - | NA | text | string |
| grids.results.units | String | Contained | 0..1 | - | g/dL | - | Observation | contained[].contained[].valueQuantity.unit | - | NA | - | string |
| grids.results.value | String | Contained | 0..1 | required | 6.8 | - | Observation | contained[].contained[].valueQuantity.value | - | NA | - | string |
| grids.results.value_type | String | Contained | 0..1 | - | null | - | Observation | contained[].contained[].extension[*].valueString | - | NA | value-type | string |
| grids | Object | Contained | 0..* | - | - | - | Composition | - | - | NA | - | TBD |
| grids.accession_number | String | Contained | 0..1 | required | 999 | - | Composition | contained[*].id | - | NA | - | TBD |
| grids.collected_date | DateTime | Contained | 0..1 | required | 2020-11-05T21:05:00Z | - | Composition | contained[].extension[].valueDateTime | - | NA | collected-date | TBD |
| grids.note | String | Contained | 0..1 | - | - | - | Composition | contained[].extension[].valueString | - | NA | note | TBD |
| grids.resulted_date | DateTime | Contained | 0..1 | required | 2020-11-05T22:17:00Z | - | Composition | contained[].extension[].valueDateTime | - | NA | result-date | TBD |
| grids.status | ValueSet | Contained | 0..1 | required | FINAL | CORRECTED, DELETED, FINAL, PENDING, PRELIMINARY, RESULTS ENTERED -- NOT VERIFIED, PARTIAL, RESULTS STATUS CHANGE TO FINAL. RESULTS DID NOT CHANGE ( DONT TRANSMIT TEST)., RESULT CANCELED DUE TO NON-PERFORMANCE, ERROR, AMENDED | Composition | contained[].extension[].valueString | - | NA | status | TBD |