R4 Draft for Comment

This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Orders and Observations Work GroupMaturity Level: 2 Trial Use Compartments: Device, Patient, Practitioner

Detailed Descriptions for the elements in the Specimen resource.

Specimen
Definition

A sample to be used for analysis.

Control1..1
Specimen.identifier
Definition

Id for specimen.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Summarytrue
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.

Control0..1
TypeIdentifier
Summarytrue
Specimen.status
Definition

The availability of the specimen.

Control0..1
Terminology BindingSpecimenStatus (Required)
Typecode
Is Modifiertrue
Summarytrue
Comments

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

Specimen.type
Definition

The kind of material that forms the specimen.

Control0..1
Terminology Bindingv2 Specimen Type (Example)
TypeCodeableConcept
Summarytrue
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
Definition

Where the specimen came from. This may be from the patient(s) or from the environment or a device.

Control1..1
TypeReference(Patient | Group | Device | Substance)
Requirements

Must know the subject context.

Summarytrue
Specimen.receivedTime
Definition

Time when specimen was received for processing or testing.

Control0..1
TypedateTime
Summarytrue
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.

Control0..*
TypeReference(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
Definition

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

Control0..*
TypeReference(ServiceRequest)
Comments

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

Specimen.collection
Definition

Details concerning the specimen collection.

Control0..1
Specimen.collection.collector
Definition

Person who collected the specimen.

Control0..1
TypeReference(Practitioner)
Summarytrue
Specimen.collection.collected[x]
Definition

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

Control0..1
TypedateTime|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
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.

Control0..1
TypeSimpleQuantity
Specimen.collection.method
Definition

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

Control0..1
Terminology BindingFHIR Specimen Collection Method (Example)
TypeCodeableConcept
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.

Control0..1
Terminology BindingSNOMED CT Body Structures (Example)
TypeCodeableConcept
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 body-structure.

Specimen.processing
Definition

Details concerning processing and processing steps for the specimen.

Control0..*
Specimen.processing.description
Definition

Textual description of procedure.

Control0..1
Typestring
Specimen.processing.procedure
Definition

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

Control0..1
Terminology BindingSpecimenProcessingProcedure (Example)
TypeCodeableConcept
Specimen.processing.additive
Definition

Material used in the processing step.

Control0..*
TypeReference(Substance)
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.

Control0..1
TypedateTime|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
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.

Control0..*
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.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Summarytrue
Specimen.container.description
Definition

Textual description of the container.

Control0..1
Typestring
Specimen.container.type
Definition

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

Control0..1
Terminology BindingSpecimenContainer (Example)
TypeCodeableConcept
Specimen.container.capacity
Definition

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

Control0..1
TypeSimpleQuantity
Specimen.container.specimenQuantity
Definition

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

Control0..1
TypeSimpleQuantity
Specimen.container.additive[x]
Definition

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

Control0..1
Terminology Bindingv2 Additive/Preservative (Example)
TypeCodeableConcept|Reference(Substance)
[x] NoteSee Choice of Data Types for further information about how to use [x]
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).

Control0..*
TypeAnnotation