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ref Template  Laboratory Observation

Id 1.3.6.1.4.1.19376.1.3.1.6 ref (from repository: iheptv-) Effective Date valid from 2008‑08‑08
Status review In Review Version Label 2008
Name LaboratoryObservation Display Name Laboratory Observation
Description The document SHALL contain at least one Laboratory Observation (See REFERENCE) under the Specimen Act of each Laboratory Data Processing Entry (See REFERENCE). The Laboratory Observation SHALL record a single laboratory observation in the document, either standalone or as part of a battery. It should be distinguished from the PCC Simple Observation template.
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.1.6
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 6 templates, Uses 6 templates
Used by Template id as Name Version
1.3.6.1.4.1.19376.1.3.1.6 Containment Laboratory Observation 2008‑08‑08
2.16.840.1.113883.3.1937.99.61.26.10.26 link BC Laboratory Battery Organizer 2016‑04‑05 01:44:00
2.16.840.1.113883.3.1937.99.61.26.10.25 link BC Laboratory Report Data Processing Entry 2016‑04‑05 01:31:43
2.16.840.1.113883.3.1937.99.61.26.10.35 link BC CDA Laboratory Report Item Section 2016‑04‑05 02:22:00
2.16.840.1.113883.3.1937.99.61.26.10.24 link BC CDA LabResultSpecialtyStructuredBody 2016‑04‑05 00:27:44
2.16.840.1.113883.3.1937.99.61.26.10.28 link BC Laboratory Observation 2016‑04‑05 01:50:49
Uses Template id as Name Version
1.3.6.1.4.1.19376.1.3.3.1.2.1 Containment NonHumanSubject DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.3.1 Containment Humanpatientwithnonhumansubject DYNAMIC
2.16.840.1.113883.10.12.323 Containment CDAPerformerBody DYNAMIC
2.16.840.1.113883.10.12.318 Containment CDAAuthorBody DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment AnnotationComment DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.1.6"/>
  <id root=" " extension=" "/>
  <code code="10912-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Lead Measurement, Quantitative">
    <originalText>
      <reference value="pbTest"/>
    </originalText>  </code>  <statusCode code="completed"/>
  <effectiveTime value="20071108000000.0000-0500"/>
  <value xsi:type="PQ" unit="mg/dL" value="6.4"/>
  <interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/>
  <methodCode code=" " codeSystem=" " codeSystemName=" "/>
  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id extension="555847399003" root="1.3.6.1.4.1.19376.1.3.4"/>
      <specimenPlayingEntity>
        <code code="BLD" codeSystem="2.16.840.1.113883.5.129" codeSystemName="HL7" displayName="Blood"/>
      </specimenPlayingEntity>    </specimenRole>  </specimen>  <performer typeCode="PRF">
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/>
    <!-- ... -->
  </performer>  <author typeCode="AUT">
    <!-- ... -->
  </author>  <participant typeCode="AUTHEN">
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.5"/>
    <!-- ... -->
  </participant>  <participant typeCode="RESP">
    <!-- ... -->
  </participant>  <participant typeCode="DEV">
    <!-- ... -->
  </participant>  <entryRelationship typeCode="COMP">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.40"/>
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>
      <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/>
      <text>
        <reference value="pbTestComment"/>
      </text>      <statusCode code="completed"/>
    </act>  </entryRelationship>  <entryRelationship typeCode="REFR">
    <sequenceNumber value="1"/>
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.3.1.6"/>
      <code code="10912-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Lead Measurement, Quantitative">
        <originalText>
          <reference value="pbTest"/>
        </originalText>      </code>      <statusCode code="completed"/>
      <effectiveTime value="20071101000000.0000-0500"/>
      <value xsi:type="PQ" unit="mg/dL" value="8.7"/>
      <interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/>
      <entryRelationship typeCode="COMP">
        <act classCode="ACT" moodCode="EVN">
          <templateId root="2.16.840.1.113883.10.20.1.40"/>
          <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>
          <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/>
          <text>
            <reference value="pbTestComment"/>
          </text>          <statusCode code="completed"/>
        </act>      </entryRelationship>    </observation>  </entryRelationship>  <referenceRange typeCode="REFV">
    <observationRange classCode="OBS" moodCode="EVN.CRT">
      <value xsi:type="IVL_PQ">
        <low value="0.0" unit="mg/dL"/>
        <high value="5.0" unit="mg/dL"/>
      </value>      <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
    </observationRange>    <lab:precondition typeCode="PRCN">
      <lab:criterion classCode="COND">
        <lab:code code="AGE"/>
        <lab:value xsi:type="IVL_PQ">
          <lab:low value="35" unit="Y"/>
          <lab:high value="55" unit="Y"/>
        </lab:value>      </lab:criterion>    </lab:precondition>  </referenceRange></observation>
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.1.3"/>
  <code code="11273-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ERYTHROCYTES"/>
  <statusCode code="completed"/>
  <effectiveTime value="20060321063000.0000-0500"/>
  <value xsi:type="PQ" value="4.95" unit="10*6/mm3"/>
  <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
  <entryRelationship typeCode="REFR">
    <!-- Previous result 4.85 from Mar 12, 2006 08:15 -->
    <observation classCode="OBS" moodCode="EVN">
      <code code="11273-0" codeSystem="2.16.840.1.113883.6.1"/>
      <statusCode code="completed"/>
      <effectiveTime value="20060312081500.0000-0500"/>
      <value xsi:type="PQ" value="4.85" unit="10*6/mm3"/>
    </observation>  </entryRelationship>  <!-- reference range given patient sex -->
  <referenceRange typeCode="REFV">
    <observationRange classCode="OBS" moodCode="EVN.CRT">
      <value xsi:type="IVL_PQ">
        <low value="4.50" unit="10*6/mm3"/>
        <high value="6.00" unit="10*6/mm3"/>
      </value>    </observationRange>    <lab:precondition typeCode="PRCN">
      <lab:criterion classCode="COND">
        <lab:code code="SEX"/>
        <lab:value xsi:type="CD" code="M" codeSystem="2.16.840.1.113883.5.1"/>
      </lab:criterion>    </lab:precondition>  </referenceRange></observation>
Item DT Card Conf Description Label
hl7:observation
1 … 1 M (LaboratoryObservation)
treetree @classCode
1 … 1 F OBS
treetree @moodCode
1 … 1 F EVN
treetree hl7:templateId
II 1 … 1 M (LaboratoryObservation)
treeblank treetree @root
1 … 1 F 1.3.6.1.4.1.19376.1.3.1.6
treetree hl7:id
II 0 … 1 A Laboratory Observation identifier MAY be present. (LaboratoryObservation)
treetree hl7:code
CE 1 … 1 R Unique test code in an international standard (LOINC or SNOMED CT) or a national standard (e.g. JC10 in Japan) (LaboratoryObservation)
treetree hl7:statusCode
CS 1 … 1 M ‘completed’ when the result is present.
‘aborted’ if the test could not be performed. 		(LaboratoryObservation)
  CONF
@code shall be "completed"
or
@code shall be "aborted"
treetree hl7:effectiveTime
TS 0 … 1 R Physiologically relevant time (LaboratoryObservation)
treetree hl7:value
ANY 0 … 1 R The result obtained for this test using the appropriate data type. Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘obsolete’ or ‘aborted’ observation. (LaboratoryObservation)
treeblank treetree @xsi:type
1 … 1 F ANY
treetree hl7:interpretationCode
CE 0 … 1 R One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g. H = high, L = low)
In case of a antimicrobial susceptibility test in microbiology, the vocabulary domain is ObservationInterpretationSusceptibility: S = susceptible, R = resistant, I = intermediate, VS = very susceptible, MS = moderately susceptible 		(LaboratoryObservation)
  CONF
shall be drawn from concept domain "Observation Interpretation"
treetree hl7:methodCode
CE 0 … 1 R method used for this observation expressed with ObservationMethod vocabulary (CWE) (LaboratoryObservation)
  CONF
shall be drawn from concept domain "Observation Method"
Choice  … 1 Elements to choose from:
treeblank treetree hl7:subject
0 … 1 subject in case of a non-human subject attached to the isolate
Contains 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMIC) 		(LaboratoryObservation)
where [hl7:subject [hl7:templateId/@root='1.3.6.1.4.1.19376.1.3.3.1.2.1']]
treeblank treeblank treetree @typeCode
0 … 1 F SBJ
treeblank treetree hl7:subject
0 … 1 subject in case of a non-human subject attached to the isolate
Contains 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMIC) 		(LaboratoryObservation)
where [hl7:subject [hl7:templateId/@root='1.3.6.1.4.1.19376.1.3.3.1.3.1']]
treeblank treeblank treetree @typeCode
0 … 1 F SBJ
treetree hl7:specimen
0 … 1 R specimen participation if this observation uses a specific specimen not recorded at a higher level. (LaboratoryObservation)
treeblank treetree @typeCode
1 … 1 F SPC
treeblank treetree hl7:specimenRole
0 … 1 (LaboratoryObservation)
treeblank treeblank treetree @classCode
1 … 1 F SPEC
treeblank treeblank treetree hl7:id
II 0 … 1 specimen identifier known to the laboratory (LaboratoryObservation)
treeblank treeblank treetree hl7:specimenPlayingEntity
1 … 1 (LaboratoryObservation)
treeblank treeblank treeblank treetree hl7:code
CE 1 … 1 M The specimen type coded with HL7 vocabulary SpecimenEntityType or another standard vocabulary (LaboratoryObservation)
  CONF
shall be drawn from concept domain "Specimen Entity Type"
treeblank treeblank treetree lab:productOf
0 … 1 Extension to CDA Clinical Statement (LaboratoryObservation)
treeblank treeblank treeblank treetree @typeCode
1 … 1 F PRD
  Example <lab:productOf typeCode="PRD">
  <lab:procedure classCode="PROC" moodCode="EVN">
    <lab:effectiveTime value="200603210630"/>
  </lab:procedure></lab:productOf>
treeblank treeblank treeblank treetree lab:procedure
(LaboratoryObservation)
treeblank treeblank treeblank treeblank treetree @classCode
1 … 1 F PROC
treeblank treeblank treeblank treeblank treetree @moodCode
1 … 1 F EVN
treeblank treeblank treeblank treeblank treetree lab:code
CE 0 … 1 (LaboratoryObservation)
treeblank treeblank treeblank treeblank treetree lab:effectiveTime
IVL_TS 1 … 1 M (LaboratoryObservation)
treeblank treeblank treeblank treeblank treetree lab:targetSiteCode
CD 0 … * (LaboratoryObservation)
treetree hl7:performer
0 … 1 R performer participation. Performer to supersede those recorded at higher level.
Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC) 		(LaboratoryObservation)
treeblank treetree @typeCode
1 … 1 F PRF
treetree hl7:author
0 … * R author participation used to supersede the authors of higher level.
Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) 		(LaboratoryObservation)
treeblank treetree @typeCode
1 … 1 F AUT
Choice  … 3 Elements to choose from:
  • hl7:participant[@typeCode='AUTHEN']
  • hl7:participant[@typeCode='RESP']
  • hl7:participant[@typeCode='DEV']
treeblank treetree hl7:participant
0 … 1 Other participants "AUTHEN", "RESP", and "DEV".
  • AUTHEN: The verifier of the battery organizer. In the case where a laboratory report has multiple verifiers. Each verifier is attached to the subset of batteries/observations he or she verified, by the means of a <participant> element.
(LaboratoryObservation)
where [@typeCode='AUTHEN']
treeblank treeblank treetree @typeCode
1 … 1 F AUTHEN
treeblank treetree hl7:participant
0 … 1 Other participants "AUTHEN", "RESP", and "DEV".
  • RESP: The person responsible for the provision of the battery. In the case where this battery is subcontracted to an external laboratory, this external laboratory (with its address and telcom) and the actual performer is represented by a <performer> element, whereas the Director of this subcontractor laboratory is carried by the <participant> element being attached to the same level as the <performer> element.
(LaboratoryObservation)
where [@typeCode='RESP']
treeblank treeblank treetree @typeCode
1 … 1 F RESP
treeblank treetree hl7:participant
0 … 1 Other participants "AUTHEN", "RESP", and "DEV".
  • DEV: A device or equipment, which was used to produce this battery of results (e.g. an analyzer).
(LaboratoryObservation)
where [@typeCode='DEV']
treeblank treeblank treetree @typeCode
1 … 1 F DEV
treetree hl7:entryRelationship
0 … * R Comment on this Observation
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 Annotation Comment (DYNAMIC) 		(LaboratoryObservation)
where [@typeCode='COMP']
treeblank treetree @typeCode
1 … 1 F COMP
treetree hl7:entryRelationship
0 … * R Previous observations obtained for the same patient, test, same method, same unit (1)
Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (DYNAMIC) 		(LaboratoryObservation)
where [@typeCode='REFR']
treeblank treetree @typeCode
1 … 1 F REFR
treeblank treetree hl7:sequenceNumber
INT 0 … 1 R (LaboratoryObservation)
  Schematron assert role red error  
  test hl7:observation/hl7:statusCode[@code='completed']  
  Message Status code of previous observations must be 'completed'  
treetree hl7:referenceRange
0 … 1 R Reference range for the current test result (LaboratoryObservation)
treeblank treetree @typeCode
1 … 1 F REFV
treeblank treetree hl7:observationRange
1 … 1 M (LaboratoryObservation)
treeblank treeblank treetree @classCode
1 … 1 F OBS
treeblank treeblank treetree @moodCode
1 … 1 F EVN.CRT
treeblank treeblank treetree hl7:value
0 … 1 (LaboratoryObservation)
treeblank treeblank treetree hl7:interpretationCode
CV 1 … 1 R (LaboratoryObservation)
treeblank treeblank treeblank treetree @code
1 … 1 F N
treeblank treeblank treeblank treetree @codeSystem
1 … 1 F 2.16.840.1.113883.5.83 (Observation Interpretation)
treeblank treeblank treetree lab:precondition
0 … * Extension to CDA Clinical statement (LaboratoryObservation)
treeblank treeblank treeblank treetree @typeCode
1 … 1 F PRCN
treeblank treeblank treeblank treetree lab:criterion
1 … 1 (LaboratoryObservation)
treeblank treeblank treeblank treeblank treetree @classCode
1 … 1 F COND
treeblank treeblank treeblank treeblank treetree @moodCode
1 … 1 F EVN
treeblank treeblank treeblank treeblank treetree lab:code
CE 1 … 1 R Code of the criterion (e.g. age, sex) (LaboratoryObservation)
treeblank treeblank treeblank treeblank treetree lab:value
1 … 1 R (LaboratoryObservation)