Document - LFT-UandE-Report-Example - England Pathology and Laboratory Medicine (PaLM) Technical Framework v0.1.0

England Pathology and Laboratory Medicine (PaLM) Technical Framework
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Example Bundle: Document - LFT-UandE-Report-Example

Document Details

Language: en

Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Bundle-Lab-Pathology|0.1.0

Final Document at 2022-03-08 14:23:00+0000 by TD008362 PATH LAB 001 for ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)

Document Subject

Language: en

Profile: Patient (EU core) version: 2.0.1

ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)

Other Ids:

Patient internal identifier/Y8J7D0381527
National Health Plan Identifier/9999999468

Contact Detail

B6 5RQ

Document Content

NHS Number	9999999468
Report number	REP-20220308-008902
Status	final
Requested by	Dr Gale GASKELL, PICKERING MEDICAL PRACTICE (B82033)
Laboratory	TD008362 PATH LAB 001 (Y8J7D)
Specimen	Venous blood specimen collected 2022-03-07T10:02:00+00:00
Issued	2022-03-08T14:23:00+00:00

Liver function tests

Test	Result	Units	Reference range
Serum total bilirubin level	6	umol/L	< 21
Serum albumin level	47	g/L	35 - 50
Serum alkaline phosphatase level	96	iu/L	30 - 130
Serum alanine aminotransferase level	15	iu/L	< 40

Urea and electrolytes level

Test	Result	Units	Reference range
Serum urea level	3.7	mmol/L	2.5 - 7.8
Serum sodium level	139	mmol/L	133 - 146
Serum potassium level	4.7	mmol/L	3.5 - 5.3
Serum creatinine level	73	umol/L	59 - 104
eGFR (estimated glomerular filtration rate) using creatinine Chronic Kidney Disease Epidemiology Collaboration equation per 1.73 square metres	100	mL/min/1.73m2

eGFR (estimated glomerular filtration rate) using creatinine Chronic Kidney Disease Epidemiology Collaboration equation per 1.73 square metres: Calculated eGFR is not valid in children or pregnancy.
Less accurate with acute change in creatinine (AKI).
Caution with high or low muscle mass or amputation.
Avoid blood sampling within 12 hours of eating meat.
Ethnicity factor comment removed Dec21 NG203.

Additional Resources Included in Document

Entry 2 - fullUrl = urn:uuid:f4ce5504-3821-5939-8131-96727eda4722

Resource DiagnosticReport:

Language: en
Profile: http://hl7.eu/fhir/laboratory/StructureDefinition/DiagnosticReport-eu-lab|2.0.0-nhs-fix
Diagnostic studies report (Chemistry, General pathology (specialty))
Subject ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
Relevant Time 2022-03-07 10:02:00+0000
Reported 2022-03-08 14:23:00+0000
Performer TD008362 PATH LAB 001
Identifier Filler Identifier/REP-20220308-008902
Report Details
Code Value Flags
Liver function tests Final
Urea and electrolytes level Final

Entry 3 - fullUrl = urn:uuid:5034f823-2354-50e0-8023-1b3cf29cd7dc

Resource ServiceRequest:

Language: en
Profile: http://hl7.eu/fhir/laboratory/StructureDefinition/ServiceRequest-eu-lab|2.0.0
identifier: Placer Identifier/REQ-20220307-000046-001, Filler Identifier/REP-20220308-008902
status: Completed
intent: Order
code: No display for ServiceRequest.code (concept: Liver function tests)
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
authoredOn: 2022-03-07 09:48:00+0000
requester: Dr Gale GASKELL at PICKERING MEDICAL PRACTICE
performer: TD008362 PATH LAB 001

Entry 4 - fullUrl = urn:uuid:e1a2c957-a745-501b-880c-358c673f2013

Resource ServiceRequest:

Language: en
Profile: http://hl7.eu/fhir/laboratory/StructureDefinition/ServiceRequest-eu-lab|2.0.0
identifier: Placer Identifier/REQ-20220307-000046-002, Filler Identifier/REP-20220308-008902
status: Completed
intent: Order
code: No display for ServiceRequest.code (concept: Urea and electrolytes level)
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
authoredOn: 2022-03-07 09:48:00+0000
requester: Dr Gale GASKELL at PICKERING MEDICAL PRACTICE
performer: TD008362 PATH LAB 001

Entry 5 - fullUrl = urn:uuid:bfe333d7-2a8c-5dae-a44a-5d3b120d2ef5

Resource Patient:

Language: en
Profile: Patient (EU core) version: 2.0.1
ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
Other Ids:
Patient internal identifier/Y8J7D0381527
National Health Plan Identifier/9999999468
Contact Detail B6 5RQ

Entry 6 - fullUrl = urn:uuid:44b4c2c2-e882-59cb-bcab-4db2c6ed512b

Resource Organization:

Language: en
Profile: https://fhir.hl7.org.uk/StructureDefinition/UKCore-Organization|2.5.0
TD008362 PATH LAB 001 (https://fhir.nhs.uk/Id/ods-organization-code#ODS Organisation Code#Y8J7D)
Contact Detail
PATHOLOGY LAB 7-8 WELLINGTON PLACE LEEDS LS1 4AP

Entry 7 - fullUrl = urn:uuid:e1fae66a-128e-57f2-a3c0-41647ca6076b

Resource Specimen:

Language: en
Profile: http://hl7.eu/fhir/laboratory/StructureDefinition/Specimen-eu-lab|2.0.0
identifier: Placer Identifier/SPC-REQ-20220307-000014
status: Available
type: Venous blood specimen
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
receivedTime: 2022-03-07 14:54:00+0000
request: ServiceRequest Liver function tests
Collections
- Collected[x]
* 2022-03-07 10:02:00+0000

Entry 8 - fullUrl = urn:uuid:32f8a5ae-c597-54ac-b65c-2d1edfc352f2

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
Extension UK Core Observation Organizer: true
basedOn: ServiceRequest Liver function tests
status: Final
category: Laboratory, General pathology (specialty)
code: Liver function tests
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
hasMember:
Observation Serum total bilirubin level
Observation Serum albumin level
Observation Serum alkaline phosphatase level
Observation Serum alanine aminotransferase level

Entry 9 - fullUrl = urn:uuid:91b76c07-cbc7-5a01-9b90-e6b4eea3fd80

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
Extension UK Core Observation Organizer: true
basedOn: ServiceRequest Urea and electrolytes level
status: Final
category: Laboratory, General pathology (specialty)
code: Urea and electrolytes level
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
hasMember:
Observation Serum urea level
Observation Serum sodium level
Observation Serum potassium level
Observation Serum creatinine level
Observation eGFR (estimated glomerular filtration rate) using creatinine Chronic Kidney Disease Epidemiology Collaboration equation per 1.73 square metres

Entry 10 - fullUrl = urn:uuid:84c94bb1-4336-5607-9124-6b82052db22a

Resource PractitionerRole:

Language: en
Profile: https://fhir.hl7.org.uk/StructureDefinition/UKCore-PractitionerRole|2.4.0
Dr Gale GASKELL at PICKERING MEDICAL PRACTICE
Practitioner: Dr Gale GASKELL
Organization: PICKERING MEDICAL PRACTICE

Entry 11 - fullUrl = urn:uuid:a710f661-d19a-57c2-a0c2-41242f538809

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
basedOn: ServiceRequest Liver function tests
status: Final
category: Laboratory, General pathology (specialty)
code: Serum total bilirubin level
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
value: 6 umol/L (Details: UCUM codeumol/L = 'umol/L')
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
ReferenceRanges
- High
* 21 umol/L (Details: UCUM codeumol/L = 'umol/L')

Entry 12 - fullUrl = urn:uuid:2fd38bf8-4ca6-5014-bce1-bbdc3d02b455

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
basedOn: ServiceRequest Liver function tests
status: Final
category: Laboratory, General pathology (specialty)
code: Serum albumin level
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
value: 47 g/L (Details: UCUM codeg/L = 'g/L')
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
ReferenceRanges
- Low High
* 35 g/L (Details: UCUM codeg/L = 'g/L') 50 g/L (Details: UCUM codeg/L = 'g/L')

Entry 13 - fullUrl = urn:uuid:b2b377cb-8999-5ad4-a3a7-0ebf744f6385

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
basedOn: ServiceRequest Liver function tests
status: Final
category: Laboratory, General pathology (specialty)
code: Serum alkaline phosphatase level
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
value: 96 iu/L (Details: UCUM code[iU]/L = '[iU]/L')
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
ReferenceRanges
- Low High
* 30 iu/L (Details: UCUM code[iU]/L = '[iU]/L') 130 iu/L (Details: UCUM code[iU]/L = '[iU]/L')

Entry 14 - fullUrl = urn:uuid:67f8aca5-cf0d-5db2-9338-98f605fc85bc

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
basedOn: ServiceRequest Liver function tests
status: Final
category: Laboratory, General pathology (specialty)
code: Serum alanine aminotransferase level
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
value: 15 iu/L (Details: UCUM code[iU]/L = '[iU]/L')
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
ReferenceRanges
- High
* 40 iu/L (Details: UCUM code[iU]/L = '[iU]/L')

Entry 15 - fullUrl = urn:uuid:9667895d-62e6-54ac-9ae0-5a614c3aa4d4

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
basedOn: ServiceRequest Urea and electrolytes level
status: Final
category: Laboratory, General pathology (specialty)
code: Serum urea level
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
value: 3.7 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
ReferenceRanges
- Low High
* 2.5 mmol/L (Details: UCUM codemmol/L = 'mmol/L') 7.8 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 16 - fullUrl = urn:uuid:b454e50d-add5-5d43-bf30-3e74d00b748b

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
basedOn: ServiceRequest Urea and electrolytes level
status: Final
category: Laboratory, General pathology (specialty)
code: Serum sodium level
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
value: 139 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
ReferenceRanges
- Low High
* 133 mmol/L (Details: UCUM codemmol/L = 'mmol/L') 146 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 17 - fullUrl = urn:uuid:75268412-928e-5545-95f0-50dae673af89

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
basedOn: ServiceRequest Urea and electrolytes level
status: Final
category: Laboratory, General pathology (specialty)
code: Serum potassium level
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
value: 4.7 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
ReferenceRanges
- Low High
* 3.5 mmol/L (Details: UCUM codemmol/L = 'mmol/L') 5.3 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 18 - fullUrl = urn:uuid:f6f51c99-e09c-5d75-b6ba-c11787b54760

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
basedOn: ServiceRequest Urea and electrolytes level
status: Final
category: Laboratory, General pathology (specialty)
code: Serum creatinine level
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
value: 73 umol/L (Details: UCUM codeumol/L = 'umol/L')
specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000
ReferenceRanges
- Low High
* 59 umol/L (Details: UCUM codeumol/L = 'umol/L') 104 umol/L (Details: UCUM codeumol/L = 'umol/L')

Entry 19 - fullUrl = urn:uuid:b2e68e13-b395-5f61-b2c4-4aa8e4062edc

Resource Observation:

Language: en
Profile: https://fhir.nhs.uk/England/StructureDefinition/England-Observation-Lab-Pathology|0.2.1
basedOn: ServiceRequest Urea and electrolytes level
status: Final
category: Laboratory, General pathology (specialty)
code: eGFR (estimated glomerular filtration rate) using creatinine Chronic Kidney Disease Epidemiology Collaboration equation per 1.73 square metres
subject: ONE John EDITESTPATIENT Male, DoB: 1925-01-27 ( Medical record number: RCB4719263)
effective: 2022-03-07 10:02:00+0000
issued: 2022-03-08 14:23:00+0000
performer: TD008362 PATH LAB 001
value: 100 mL/min/1.73m2 (Details: UCUM codemL/min/((173/100).m2) = 'mL/min/((173/100).m2)')
note:
Calculated eGFR is not valid in children or pregnancy. Less accurate with acute change in creatinine (AKI). Caution with high or low muscle mass or amputation. Avoid blood sampling within 12 hours of eating meat. Ethnicity factor comment removed Dec21 NG203.

specimen: Specimen: identifier = Placer Identifier: SPC-REQ-20220307-000105; accessionIdentifier = Accession ID: SPC-Lab-20220307-007856; status = available; type = Venous blood specimen; receivedTime = 2022-03-07 14:58:00+0000

Entry 20 - fullUrl = urn:uuid:73062312-924a-5a6d-972b-1a454bb5a8c6

Resource Practitioner:

Language: en
Profile: https://fhir.hl7.org.uk/StructureDefinition/UKCore-Practitioner|2.4.0
Gale GASKELL (official) (https://fhir.hl7.org.uk/Id/gmc-number#GMC Number#C1008215)

Entry 21 - fullUrl = urn:uuid:7f2280d3-a318-510e-98c8-389ad7c30671

Resource Organization:

Language: en
Profile: https://fhir.hl7.org.uk/StructureDefinition/UKCore-Organization|2.5.0
PICKERING MEDICAL PRACTICE (https://fhir.nhs.uk/Id/ods-organization-code#ODS Organisation Code#B82033)
Contact Detail
SOUTHGATE PICKERING YO18 8BL

Entry 22 - fullUrl = urn:uuid:25caa3c2-2abe-5027-95a5-902232469a2f

Resource Provenance:

Laboratory report REP-20220308-008902 sent by product EXAMPLE-PRODUCT:Y8J7D.

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