Release 4 5 Preview #2
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Orders and Observations Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Device , Patient , Practitioner

Detailed Descriptions for the elements in the Specimen resource.

Specimen
Element Id Specimen
Definition

A sample to be used for analysis.

Cardinality 0..*
Type DomainResource
Specimen.identifier
Element Id Specimen.identifier
Definition

Id for specimen.

Note This is a business identifier, not a resource identifier (see discussion )
Cardinality 0..*
Type Identifier
Summary true
Specimen.accessionIdentifier
Element Id Specimen.accessionIdentifier
Definition

The identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures.

Cardinality 0..1
Type Identifier
Summary true
Specimen.status
Element Id Specimen.status
Definition

The availability of the specimen.

Cardinality 0..1
Terminology Binding SpecimenStatus ( Required )
Type code
Is Modifier true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summary true
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Specimen.type
Element Id Specimen.type
Definition

The kind of material that forms the specimen.

Cardinality 0..1
Terminology Binding v2 Specimen Type ( Example )
Type CodeableConcept
Summary true
Comments

The type can change the way that a specimen is handled and drives what kind of analyses can properly be performed on the specimen. It is frequently used in diagnostic work flow decision making systems.

Specimen.subject
Element Id Specimen.subject
Definition

Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device.

Cardinality 0..1
Type Reference ( Patient | Group | Device | Substance | Location )
Patterns Reference(Patient,Group,Device,Substance,Location): No common pattern
Requirements

Must know the subject context.

Summary true
Specimen.receivedTime
Element Id Specimen.receivedTime
Definition

Time when specimen was received for processing or testing.

Cardinality 0..1
Type dateTime
Summary true
Specimen.parent
Element Id Specimen.parent
Definition

Reference to the parent (source) specimen which is used when the specimen was either derived from or a component of another specimen.

Cardinality 0..*
Type Reference ( Specimen )
Comments

The parent specimen could be the source from which the current specimen is derived by some processing step (e.g. an aliquot or isolate or extracted nucleic acids from clinical samples) or one of many specimens that were combined to create a pooled sample.

Specimen.request
Element Id Specimen.request
Definition

Details concerning a service request that required a specimen to be collected.

Cardinality 0..*
Type Reference ( ServiceRequest )
Comments

The request may be explicit or implied such with a ServiceRequest that requires a blood draw.

Specimen.collection
Element Id Specimen.collection
Definition

Details concerning the specimen collection.

Cardinality 0..1
Specimen.collection.collector
Element Id Specimen.collection.collector
Definition

Person who collected the specimen.

Cardinality 0..1
Type Reference ( Practitioner | PractitionerRole )
Patterns Reference(Practitioner,PractitionerRole): Common patterns = Participant
Summary true
Specimen.collection.collected[x]
Element Id Specimen.collection.collected[x]
Definition

Time when specimen was collected from subject - the physiologically relevant time.

Cardinality 0..1
Type dateTime | Period
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
Specimen.collection.duration
Element Id Specimen.collection.duration
Definition

The span of time over which the collection of a specimen occurred.

Cardinality 0..1
Type Duration
Summary true
Specimen.collection.quantity
Element Id Specimen.collection.quantity
Definition

The quantity of specimen collected; for instance the volume of a blood sample, or the physical measurement of an anatomic pathology sample.

Cardinality 0..1
Type SimpleQuantity
Specimen.collection.method
Element Id Specimen.collection.method
Definition

A coded value specifying the technique that is used to perform the procedure.

Cardinality 0..1
Terminology Binding FHIR Specimen Collection Method ( Example )
Type CodeableConcept
Specimen.collection.bodySite
Element Id Specimen.collection.bodySite
Definition

Anatomical location from which the specimen was collected (if subject is a patient). This is the target site. This element is not used for environmental specimens.

Cardinality 0..1
Terminology Binding SNOMED CT Body Structures ( Example )
Type CodeableConcept
Comments

If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension bodySite .

Specimen.collection.fastingStatus[x]
Element Id Specimen.collection.fastingStatus[x]
Definition

Abstinence or reduction from some or all food, drink, or both, for a period of time prior to sample collection.

Cardinality 0..1
Terminology Binding v2 Relevant Clincial Information ( Extensible )
Type CodeableConcept | Duration
[x] Note See Choice of Data Types for further information about how to use [x]
Requirements

Many diagnostic tests require fasting to facilitate accurate interpretation.

Summary true
Comments

Representing fasting status using this element is preferred to representing it with an observation using a 'pre-coordinated code' such as LOINC 2005-7 (Calcium [Moles/​time] [Moles/​time] in 2 hour Urine --12 hours fasting), or using a component observation such as Observation.component code` = LOINC 49541-6 (Fasting status - Reported).

Specimen.processing
Element Id Specimen.processing
Definition

Details concerning processing and processing steps for the specimen.

Cardinality 0..*
Specimen.processing.description
Element Id Specimen.processing.description
Definition

Textual description of procedure.

Cardinality 0..1
Type string
Specimen.processing.procedure
Element Id Specimen.processing.procedure
Definition

A coded value specifying the procedure used to process the specimen.

Cardinality 0..1
Terminology Binding Specimen processing procedure ( Example )
Type CodeableConcept
Specimen.processing.additive
Element Id Specimen.processing.additive
Definition

Material used in the processing step.

Cardinality 0..*
Type Reference ( Substance )
Specimen.processing.time[x]
Element Id Specimen.processing.time[x]
Definition

A record of the time or period when the specimen processing occurred. For example the time of sample fixation or the period of time the sample was in formalin.

Cardinality 0..1
Type dateTime | Period
[x] Note See Choice of Data Types for further information about how to use [x]
Specimen.container
Element Id Specimen.container
Definition

The container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here.

Cardinality 0..*
Specimen.container.identifier
Element Id Specimen.container.identifier
Definition

Id for container. There may be multiple; a manufacturer's bar code, lab assigned identifier, etc. The container ID may differ from the specimen id in some circumstances.

Note This is a business identifier, not a resource identifier (see discussion )
Cardinality 0..*
Type Identifier
Summary true
Specimen.container.description
Element Id Specimen.container.description
Definition

Textual description of the container.

Cardinality 0..1
Type string
Specimen.container.type
Element Id Specimen.container.type
Definition

The type of container associated with the specimen (e.g. slide, aliquot, etc.).

Cardinality 0..1
Terminology Binding Specimen container ( Example )
Type CodeableConcept
Specimen.container.capacity
Element Id Specimen.container.capacity
Definition

The capacity (volume or other measure) the container may contain.

Cardinality 0..1
Type SimpleQuantity
Specimen.container.specimenQuantity
Element Id Specimen.container.specimenQuantity
Definition

The quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type.

Cardinality 0..1
Type SimpleQuantity
Specimen.container.additive[x]
Element Id Specimen.container.additive[x]
Definition

Introduced substance to preserve, maintain or enhance the specimen. Examples: Formalin, Citrate, EDTA.

Cardinality 0..1
Terminology Binding v2 Additive ( Example )
Type CodeableConcept | Reference ( Substance )
[x] Note See Choice of Data Types for further information about how to use [x]
Specimen.condition
Element Id Specimen.condition
Definition

A mode or state of being that describes the nature of the specimen.

Cardinality 0..*
Terminology Binding v2 Specimen Condition ( Extensible )
Type CodeableConcept
Requirements

The specimen condition can be used to assess its quality or appropriateness for a specific test.

Summary true
Comments

Specimen condition is an observation made about the specimen. It's a point-in-time assessment. It can be used to assess its quality or appropriateness for a specific test.

Specimen.note
Element Id Specimen.note
Definition

To communicate any details or issues about the specimen or during the specimen collection. (for example: broken vial, sent with patient, frozen).

Cardinality 0..*
Type Annotation