|
|
|
|
|
Observation with related previous results, reference range, participants, comments
|
(IHELaboratoryObservation) |
 |
@classCode
|
|
cs |
1 … 1 |
F |
OBS |
|
@moodCode
|
|
cs |
1 … 1 |
F |
EVN |
|
hl7:templateId
|
|
II |
1 … 1 |
M |
|
(IHELaboratoryObservation) |
 |
|
@root
|
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.3.1.6 |
|
hl7:id
|
|
II |
0 … 1 |
|
|
(IHELaboratoryObservation) |
|
hl7:code
|
|
CD |
1 … 1 |
M |
Unique test code in an international standard (LOINC or SNOMED CT) or a national standard
(e.g., JC10 in Japan)
|
(IHELaboratoryObservation) |
|
hl7:statusCode
|
|
CS |
1 … 1 |
M |
Values:
- ‘completed’ when the result is present.
- ‘aborted’ if the test could not be performed.
|
(IHELaboratoryObservation) |
| |
CONF |
|
|
hl7:effectiveTime
|
|
IVL_TS |
0 … 1 |
|
Physiologically relevant time
|
(IHELaboratoryObservation) |
|
hl7:value
|
|
ANY |
0 … 1 |
|
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 ‘aborted’
observation.
|
(IHELaboratoryObservation) |
|
hl7:interpretationCode
|
|
CE |
0 … 1 |
|
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
- SDD = Susceptible-dose dependent
This element may be coded with other values than those of the ObservationInterpretation
vocabulary, given that the coding strength is CWE (coded with exceptions).
|
(IHELaboratoryObservation) |
| |
CONF |
|
|
hl7:methodCode
|
|
CE |
0 … 1 |
|
method used for this observation expressed with ObservationMethod vocabulary (CWE)
|
(IHELaboratoryObservation) |
| |
CONF |
|
| Choice |
0 … 1 |
|
Subject in case of a non-human subject attached to the Observation
Elements to choose from:
|
|
|
hl7:subject
|
|
|
0 … 1 |
|
Contains 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (Body) (DYNAMIC)
|
(IHELaboratoryObservation) |
| where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.3.3.1.2.1'] |
|
|
|
hl7:subject
|
|
|
0 … 1 |
|
Contains 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (Body) (DYNAMIC)
|
(IHELaboratoryObservation) |
| where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.3.3.1.3.1'] |
|
|
hl7:performer
|
|
|
0 … * |
|
Performer participation. Performer to supersede those recorded at higher level.
Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)
|
(IHELaboratoryObservation) |
| where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.3.3.1.7'] |
|
|
hl7:author
|
|
|
0 … * |
|
Author participation used to supersede the authors of higher level.
Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.17 Author with Name, Addr, Telecom (DYNAMIC)
|
(IHELaboratoryObservation) |
| Choice |
0 … * |
|
Other participants such as verifier (AUTHEN) or responsible party (RESP).
Elements to choose from:
|
|
|
hl7:participant
|
|
|
0 … * |
|
AUTHEN for verifier,
Contains 1.3.6.1.4.1.19376.1.3.3.1.5 Laboratory Results Validator (DYNAMIC)
|
(IHELaboratoryObservation) |
| where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.3.3.1.5'] |
|
|
|
hl7:participant
|
|
|
0 … * |
|
RESP for responsible party
Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.10 CDA Participant (Body, responsible party) (DYNAMIC)
|
(IHELaboratoryObservation) |
|
|
hl7:participant
|
|
|
0 … * |
|
DEV for device (e.g., lab analyzer)
Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.11 CDA Participant (Body, device) (DYNAMIC)
|
(IHELaboratoryObservation) |
|
hl7:entryRelationship
|
|
|
0 … * |
|
Specimen on this Observation
Contains 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC)
|
(IHELaboratoryObservation) |
| where [hl7:procedure [hl7:templateId/@root='1.3.6.1.4.1.19376.1.3.1.2']] |
|
|
|
@typeCode
|
|
cs |
1 … 1 |
F |
COMP |
|
hl7:entryRelationship
|
|
|
0 … * |
|
Comment on this Observation
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 BC Annotation Comment (DYNAMIC)
|
(IHELaboratoryObservation) |
| where [hl7:act [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']] |
|
|
|
@typeCode
|
|
cs |
1 … 1 |
F |
SUBJ |
| |
A related statement is made about an act, or a cluster or battery of results. In CDA
the former shall be recorded inside an <entryRelationship> element occurring at the
end of the entry.
|
|
|
@inversionInd
|
|
bl |
1 … 1 |
F |
true |
| |
The containing act is the subject (typeCode='SUBJ') of this new observation, which
is the inverse of the normal containment structure, thus inversionInd='true'.
|
|
hl7:entryRelationship
|
|
|
0 … * |
|
Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.7 Previous observation (DYNAMIC)
|
(IHELaboratoryObservation) |
|
|
@typeCode
|
|
cs |
1 … 1 |
F |
REFR |
| |
Refers to a previous observation for the same test code on a previous specimen.
|
|
|
hl7:sequenceNumber
|
|
INT |
0 … 1 |
|
In case there is more than one previous result, the entryRelationship elements are
sorted in reverse chronological order, and numbered from 1 to n by sequenceNumber.
|
(IHELaboratoryObservation) |
|
|
int |
0 … 1 |
|
Contains the sequence number.
|
|
hl7:referenceRange
|
|
|
0 … 1 |
|
|
(IHELaboratoryObservation) |
|
|
@typeCode
|
|
cs |
1 … 1 |
F |
REFV |
|
|
hl7:observationRange
|
|
|
1 … 1 |
M |
|
(IHELaboratoryObservation) |
|
|
cs |
1 … 1 |
F |
OBS |
|
|
cs |
1 … 1 |
F |
EVN.CRT |
|
|
ANY |
0 … 1 |
|
interval (IVL) representation
|
(IHELaboratoryObservation) |
|
|
CE |
1 … 1 |
M |
These are normal ranges
|
(IHELaboratoryObservation) |
|
|
|
1 … 1 |
F |
N |
|
|
|
0 … * |
|
The Clinical Statement of CDA does not support the association of a criterion with
a reference range, thus forbidding expressing in a Laboratory Report that a reference
range is conditioned by the patient’s sex, and/or the patient’s age.
The proposed extension to express these criteria is the same that has been adopted
by the “Care Continuity Document” implementation guide: It adds a precondition actRelationship
between ObservationRange class and Criterion class of the CDA entry model.
Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.8 Observation Range Pre-Condition (DYNAMIC)
|
(IHELaboratoryObservation) |
| where [hl7:criterion [hl7:code [@codeSystem='2.16.840.1.113883.5.4' or @nullFlavor]]] |
|
Template Laboratory Observation
Draft
