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draft Template  BC CDA Result Observations (V3)

Id 2.16.840.1.113883.10.20.22.2.97 Effective Date 2019‑04‑03 23:36:32
Status draft Draft Version Label 2.1
Name BCCDAResultObservationsV3 Display Name BC CDA Result Observations (V3)
Description
This template represents the results of a laboratory, radiology, or other study performed on a patient. The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus.
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 1 template
Used by as Name Version
2.16.840.1.113883.10.20.22.2.95 Containment draft Result Organizer (V3) (2.1) 2019‑04‑03 23:40:21
2.16.840.1.113883.10.20.22.2.47 link draft BC CDA Results Section (entries optional) (V3) (2.1) 2019‑03‑16 19:55:12
2.16.840.1.113883.3.51.60.2.4.1 link draft BC CDA ClinicalDocumentDischargeSummary (V3) (2.1) 2019‑03‑19 14:15:51
Uses as Name Version
2.16.840.1.113883.10.20.22.2.81 Containment draft BC CDA Author (Body) DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.20.22.2.97 (2019‑03‑16 19:49:35)
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Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
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Version: template 2.16.840.1.113883.10.20.22.2.97 (2013‑01‑31)
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Item DT Card Conf Description Label
cda:observation
(BCCdotssV3)
treetree @classCode
cs 1 … 1 F OBS CONFdots7130
  SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-7130).
treetree @moodCode
cs 1 … 1 F EVN CONFdots7131
  SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-7131).
treetree hl7:templateId
II 1 … 1 M (BCCdotssV3)
treeblank treetree @root
uid 1 … 1 F 2.16.840.1.113883.10.20.22.2.97
treetree cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1198-7136) such that it CONFdots7136
treeblank treetree @root
uid 1 … 1 F 2.16.840.1.113883.10.20.22.2.97 CONFdots9138
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.2" (CONF:1198-9138).
treeblank treetree @extension
st 1 … 1 F 2015-08-01 CONFdots2575
  SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32575).
treetree cda:id
II 1 … * SHALL contain at least one [1..*] id (CONF:1198-7137). CONFdots7137
treetree cda:code
CD 1 … 1 M SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-7133). CONFdots7133
treeblank treetree @codeSystem
CONF 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree cda:statusCode
CS 1 … 1 R SHALL contain exactly one [1..1] statusCode (CONF:1198-7134). CONFdots7134
treetree cda:effectiveTime
IVL_TS 1 … 1 SHALL contain exactly one [1..1] effectiveTime (CONF:1198-7140). CONFdots7140
treetree cda:value
1 … 1 M SHALL contain exactly one [1..1] value (CONF:1198-7143).

A coded or physical quantity value *MAY* contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab.

CONFdots7143
  Constraint If Observation/value is a physical quantity (*xsi:type*=*"PQ"*), the unit of measure *SHALL* be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 *DYNAMIC*
  Schematron assert role red error  
  test (.[@xsi:type='CD'][@codeSystem='2.16.840.1.113883.6.96']) or not(.[@xsi:type='CD'])  
  Message If Observation/value is a CD (*xsi:type*=*"CD"*) the value SHOULD be SNOMED-CT  
treetree cda:interpretationCode
0 … * R SHOULD contain zero or more [0..*] interpretationCode (CONF:1198-7147). CONFdots7147
treeblank treetree @code
1 … 1 R The interpretationCode, if present, SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78 STATIC (CONF:1198-32476). CONFdots2476
treetree cda:methodCode
CE 0 … 1 MAY contain zero or one [0..1] methodCode (CONF:1198-7148). CONFdots7148
treetree cda:targetSiteCode
CD 0 … 1 MAY contain zero or one [0..1] targetSiteCode (CONF:1198-7153). CONFdots7153
treetree cda:author
0 … * R SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-7149).
Contains 2.16.840.1.113883.10.20.22.2.81 BC CDA Author (Body) (DYNAMIC) 		CONFdots7149
treeblank where [hl7:assignedAuthor [@classCode = 'ASSIGNED']]
treetree cda:referenceRange
0 … * R SHOULD contain zero or more [0..*] referenceRange (CONF:1198-7150). CONFdots7150
treeblank treetree cda:observationRange
1 … 1 M The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:1198-7151). CONFdots7151
treeblank treeblank treetree cda:code
CD NP This observationRange SHALL NOT contain [0..0] code (CONF:1198-7152). CONFdots7152
treeblank treeblank treetree cda:value
1 … 1 R This observationRange SHALL contain exactly one [1..1] value (CONF:1198-32175). CONFdots2175