Specimen characteristic reference set

Clinical findings on the initial morphological analysis of a specimen are required to enable the laboratory to conduct the right investigation and for the pathologist to interpret and report on the results clearly and unambiguously. This reference set contains terminology for describing the clinical findings on the initial morphological analysis of a specimen, identifying attributes that may impact upon the result.

This reference set supports the accurate and unambiguous electronic communication and exchange of information relating to pathology result reporting between a pathology provider to a requesting clinician, or other approved recipient. It can be used within implementations of the Pathology Test Result DCM (Pathology Test Result Detailed Clinical Model Specification. Sydney: NEHTA; 2015. v3.1.) and the Pathology Result Report SDT (Pathology Result Report Structured Document Template. Sydney: NEHTA; 2009. v1.0.)